Aetna Life Insurance Company

Gold S: Aetna network + $0 walk-in clinic + $0 CVS Health Virtual Care 24/7

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers.
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Exclusions: No coverage for non-emergency use of the emergency room.
Urgent Care Facility	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered Exclusions: No coverage for non-urgent care.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Member cost sharing applies to postnatal care.

Vision

Routine Eye Exams for Children

CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Coverage is limited to 1 exam every 12 months through the end of the month in which the member turns 19.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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